Egg Donor Application: Getting Started

To apply to become an egg donor, please complete the form below

First name:*

Last name:*

Date of Birth *

Daytime Phone *

Email *

Please complete the form below

Egg donation is a demanding, involved process that requires commitment from you. Before filling out the application form, please read below and decide if you still want to continue with an application.

I am reachable at the phone number and email address I enter in the application form.

If I pass the initial screening of my application, I will have two interview appointments to determine my eligibility. At least one of these appointments will have to be during regular business hours, Monday to Friday, 9-5.

I will keep all my appointments, and I will inform CHR if I need to reschedule or cancel one.

I understand that after I am approved as an egg donor at CHR, it may take months or years before I am matched with a recipient. I may never be matched.

Egg donation requires daily, self-administered injections of hormonal medications and frequent office visits for blood tests and ultrasound. This typically takes 2-3 weeks. I don’t have a problem with these requirements.

I understand that egg retrieval is performed under IV sedation. Eggs are aspirated from the ovaries via vagina, using a small needle.

If I have any concerns or questions about the process, I will bring it up with the CHR staff.

Egg Donor Application: Please complete the form below.

Thank you for your interest in becoming an egg donor in our New York egg donor program. We accept both local New York egg donors and donors living elsewhere in the United States.

Please note: An application without a photo will NOT be considered. Please choose photos that show your face and/or body type clearly.

Are you already registered as an egg donor at CHR?

YES

NO

If YES, please enter your egg donor ID:

Address 1

Address 2

City

State

Zip

Home Phone

Alternate Phone

I heard about egg donation through

Who/Where?

If accepted as an egg donor I would be available to serve beginning

Immediately

Starting as of

(mm/dd/yyyy)

Do you live in the NYC area?

Do you have a social security number or a valid work permit?

Yes

No, but I am willing to donate with taxes withheld from my donor compensation.

Marital Status

Single with one partner

Single with no partner

Single and dating

Separated or Divorced

Engaged

Married

Living together

Place of Birth

City

State/Province

Country

Ethnicity (check all that apply)

Aborigine

African

Asian

Caucasian

Hispanic

Indonesian

Jewish

Mediterranean

Middle Eastern

Native American

South Asian

West Indian

Other

Enter Other:

Please select your ancestry and provide the percentage. You can add up to 8 ancestries.

Select Ancestry

Select Ancestry

%

%

Select Ancestry

Select Ancestry

%

%

Select Ancestry

Select Ancestry

%

%

Select Ancestry

Select Ancestry

%

%

Religion born into

Buddhist

Christian

Hindu

Jewish

Islamic

Enter Other:

Personal Characteristics

Height

Select Height

Weight

Enter Weight (lbs):

Build

Select Build

Eye Color

Select Eye Color

Natural Hair Color

Select Hair Color

Type of Hair (check all that apply)

Straight

Wavy

Thick

Fine

Curly

Coarse

Frizzy

Kinky

Do you wear corrective lenses

Yes

No

Are you predominantly

Right Handed

Left Handed

Skin Skin Tone

Select Skin Tone

Freckles

Select Freckles

Additional Characteristics (check all that apply)

Cleft Chin

Big Eyes

High Cheek Bones

Full Lips

Enter Other:

Education/Work/Interests

Educational Background (check all that apply)

Some High School

High School Graduate

G.E.D.

Tech/Trade School

Some College

Bachelor's Degree

Degree Achieved:

Major Area of Study:

Associate's Degree

Degree Achieved:

Major Area of Study:

Graduate Study

Graduate Degree

Degree Achieved:

Masters

MBA

Ph.D.

D.O.

M.D.

Law

Major Area of Study:

Post Graduate Study

Other

Enter Other:

S.A.T. Scores

Total Score:

Verbal:

Math:

Other Placement Scores

LSAT:

MCAT:

GRE:

Other:

Work/Occupation History

I currently work in the home

I am currently a full time student

I am currently unemployed

I currently work part time

I currently work full time

Enter Occupation:

What kind of work have you done in the past?

What kind of work is most appealing to you?

Personal Preferences/Abilities:

Are you skilled mechanically or technically?

Yes

No

How would you rate your Abilities in Mathematics

Poor

Average

Excellent

Literary Skills

Poor

Average

Excellent

Scientific/Research Ability

Poor

Average

Excellent

Athletic Abilities

Poor

Average

Excellent

Do you have a favorite sport?

Yes

No

Please list your favorite sports

How would you rate your Musical Skills/Ability

Poor

Average

Excellent

Artistic Talents

Poor

Average

Excellent

Other than English, what languages do you speak? (check all that apply)

Chinese

Czech

Farsi

French

German

Greek

Hebrew

Hungarian

Italian

Japanese

Polish

Portuguese

Russian

Spanish

Ukrainian

Other

Enter Other:

Do you have any special talents or hobbies?

Yes

No

If yes, please list your talents or hobbies

How would you describe your personality?

What is your ultimate ambition in life?

Social History

Tobacco (Check all that currently apply)

I currently smoke

I am a heavy smoker

I used to smoke but no longer do

I have never smoked cigarettes

Alcohol

I never drink alcohol

I drink times per week.

I rarely drink alcohol (less than twice a year)

Drug usage

I have never used illegal drugs

I have tried illegal drugs at least once in the past

I used to do drugs regularly but don't anymore

I am currently using one or more of the following:

Enter usages:

Have you ever used injectable drugs?

Yes

No

Unanswered

If yes, when did you last use injectable drugs?

Sexual Behavior

During the egg donation process, women who have never had a sexual intercourse will lose their virginity. Please indicate how you feel about this:

I have had sexual intercourse and this does not apply to me.

I am still a virgin, but do not mind losing my virginity when I donate my eggs.

I am still a virgin, and I do not want to lose my virginity as a result of egg donation.

Have you ever worked as a prostitute in the past?

Yes

No

Unanswered

Have you ever engaged in homosexual activities

Yes

No

Have you ever engaged in heterosexual activity with a prostitute within the previous six months?

Yes

No

Unanswered

Have you ever engaged in sexual activities with more than one partner on regular basis

Yes

No

Do you consider yourself to be bisexual

Yes

No

Do you consider yourself to be homosexual

Yes

No

Do you consider yourself to be heterosexual

Yes

No

The Law (check all that apply)

I have never had any legal trouble

I have had legal trouble in the past

If yes, explain the type of legal trouble you have had

Crimes

I have been convicted of a crime

I have spent time in prison

What was the crime you were convicted of perpetrating?

Psychological History:

Have you ever sought counseling for depression or emotional problems?

Yes

No

Have you ever taken antidepressants for more than three months at a time?

Yes

No

Unanswered

Have you ever been diagnosed with depression?

Yes

No

Unanswered

Have you ever been diagnosed with schizophrenia?

Yes

No

Unanswered

Have you ever been diagnosed with manic depression?

Yes

No

Unanswered

Have you ever been diagnosed with obsessive-compulsive disorder?

Yes

No

Unanswered

Have you ever been diagnosed with mania?

Yes

No

Unanswered

Have you ever been diagnosed with anorexia or bulimia?

Yes

No

Unanswered

Have you ever been diagnosed with self mutilation?

Yes

No

Unanswered

Personal Health History:

Do you have any allergies that you're aware of?

Yes

No

If yes, please indicate what you are allergic to

Are you allergic to any medications?

Yes

No

If yes, please tell us what medication you're allergic to

Were you or any of your relatives born with genetic disorders that led to hearing impairment?

Yes

No

Unanswered

Do you have any dietary restrictions?

Yes

No

If yes, what are your dietary restrictions, and for what reason?

Do you take any supplemental vitamins or herbal remedies on a continual basis?

Yes

No

If yes, please list what vitamins or herbal remedies you are taking

Do you take any prescription or over the counter medication on a regular or continual basis?

Yes

No

If yes, please list what medication you are currently taking

Do you exercise regularly?

Yes

No

Have you had any surgeries in the past?

Yes

No

If yes, please indicate what surgeries you have had

Have you ever had an adverse reaction to general anesthetics?

Yes

No

Unanswered

If yes, please indicate what happened, and the severity of the response

Have you ever been hospitalized for anything other than the above listed surgeries?

Yes

No

If yes, please tell us why you were hospitalized

Have you had acupuncture treatment in the last 6 months?

Yes

No

Menstrual History:

(please answer the following questions about your menstrual cycle)

How old were you when you first began to menstruate

10

11

12

13

14

15

Other

Enter Other:

How many days are there (usually) between one period to the next?

26-28

29-32

Other

Enter Other:

How many days do your periods usually last?

2-3

4-5

6-8

Other

Enter Other:

Do you ever experience mid-cycle bleeding?

Yes

No

Would you describe your menstrual cycle as

Regular

Irregular

In general, how heavy is your menstrual flow?

Light

Moderate

Heavy

Very Heavy

Have you ever taken, or are you currently taking oral contraceptives?

Yes

No

If yes, what brand and for how long?

What form of contraceptives are you currently using?

none

Abstinence

Pills

Ring

Patch

IUD

Shots (injections)

Implant

Condom or other physical barriers

Other

What methods of contraceptive have you used? Please list

Sexual Activity/History

(please answer the following questions about your sexual history)

Have you had more than 1 sex partner over the last 6 months?

Yes

No

Have you over preceding 12 months been with a sexual partner or cohabited with anyone that is a known user of drugs for non-medical reasons, had engaged in sex in return for money or drugs, had sex with a hepatitis B positive person or had sex with clinically active hepatitis C positive person?

Yes

No

Unanswered

Have you had intercourse with a bisexual or homosexual partner?

Yes

No

Unanswered

Have you had intercourse without the use of a condom in the last year?

Yes

No

Unanswered

Have any of your past or present sexual partners shown evidence of having HIV infection?

Yes

No

Unanswered

Have you ever been with a sexual partner who tested positive for a sexually transmitted disease?

Yes

No

Unanswered

If you answered yes to any of the above questions, please explain in full detail

Pregnancy History:

Have you ever been pregnant?

Yes

No

If yes, how many times have you been pregnant?

Have you ever carried a pregnancy to term?

Yes

No

If yes, were there any complications with gestation or delivery?

Yes

No

If yes, what were the complications?

How many times have you given birth?

1

2

3

4

more

Has every delivery resulted in a live birth?

Yes

No

Have you ever been told in the past, that you have sexually transmitted disease?

Yes

No

Unanswered

Have you ever been told in the past, that you have Chlamydia?

Yes

No

Unanswered

Have you ever been told in the past, that you have HIV or AIDS or HTLV?

Yes

No

Unanswered

Have you ever been told in the past, that you have condyloma?

Yes

No

Unanswered

Have you ever been told in the past, that you have Ureaplasma/Mycoplasma?

Yes

No

Unanswered

Have you ever been told in the past, that you have Autoimmune Disorder?

Yes

No

Unanswered

Have you ever been told in the past, that you have Syphilis or Gonorrhea?

Yes

No

Unanswered

Have you ever been told in the past, that you have Ovarian Cysts?

Yes

No

Unanswered

Have you ever been told in the past, that you have Multiple Sclerosis?

Yes

No

Unanswered

Have you ever been told in the past, that you have Alzheimer's Disease?

Yes

No

Unanswered

Have you ever been told in the past, that you have Tuberculosis?

Yes

No

Unanswered

Have you ever been told in the past, that you have Herpes Simplex Virus I or II?

Yes

No

Unanswered

Have you ever been told in the past, that you have Abnormal Pap Smear?

Yes

No

Unanswered

Have you ever been told in the past, that you have Cancer?

Yes

No

Unanswered

Have you in the preceding 12 months been through needle stick, open wounds, non-intact skin or mucous membrane exposed for HIV, Hepatitis A, B or Hepatitis C or ever been treated for any of these?

Yes

No

Unanswered

Have you ever been told in the past, that you have Endometriosis?

Yes

No

Unanswered

Have you ever been told in the past, that you have Fibroids?

Yes

No

Unanswered

Have you ever been told in the past, that you have Pelvic Inflammatory Disease?

Yes

No

Unanswered

Have you ever been told in the past, that you have Hypertension?

Yes

No

Unanswered

Have you ever been told in the past, that you have Endocrine Disease?

Yes

No

Unanswered

Have you ever been told in the past, that you have Sepsis?

Yes

No

Unanswered

Have you ever been told in the past, that you or relative have West Nile Virus?

Yes

No

Unanswered

Have you ever been told in the past, that you have Vaccinia?

Yes

No

Unanswered

Have you ever been told in the past, that you have Creutzfeld-Jakob disease (CJD)?

Yes

No

Unanswered

Have you ever been told in the past, that you have Chagas Disease, protozoan parasite infection, T. Cruzi?

Yes

No

Unanswered

Have you or your sexual partner traveled outside of the United States in the last 6 months?

Yes

No

Unanswered

Please list the countries you or your sexual partner traveled to in the last 6 months:

Have you been diagnosed with Zika infection in the past 6 months?

Yes

No

Unanswered

Have you lived or traveled to an area with active Zika transmission within the past 6 months?

Yes

No

Unanswered

Have you had sex within the past 6 months with a male who is known to either have been infected with Zika or have traveled to an area with active Zika transmission?

Yes

No

Unanswered

Do you have a household member or a sexual partner with Hepatitis, Zika or any other infectious diseases?

Yes

No

Unanswered

Do you have an occupation with risk of exposure to radiation or other chemicals that could be harmful to your health?

Yes

No

Unanswered

If yes, please explain what chemicals you are or have been exposed to

Have you had a Pap Smear within the past 6 months?

Yes

No

Was result of your Pap Smear within normal limits?

Yes

No

What is your blood type?

Have you received a blood transfusion within the past six months??

Yes

No

Unanswered

Have you ever received a blood transfusion or other blood products at any time in your life?

Yes

No

Unanswered

If yes, when did this happen?

Are you a current or former U.S. military or civilian military employee (or dependent), who resided on a military base in Germany, Belgium, or The Netherlands for 6 months or more between 1980-1990?

Yes

No

Are you a current or former U.S. military or civilian military employee (or dependent), who resided on a military base in Greece, Turkey, Spain, Portugal, or Italy for 6 months or more between 1980-1996?

Yes

No

Have you ever spent 5 or more cumulative years in Europe?

Yes

No

Did you spend 3 or more cumulative months in the U.K. between 1980-1996?

Yes

No

Have you received any blood transfusions or transfusions of blood products in the U.K. or France?

I hereby certify that my answers and explanations, which were voluntarily given in this questionnaire, are correct. I understand that the answers used in this questionnaire will be used to determine my appropriateness as a donor and to help match me with a prospective recipient. I will allow CHR to share any of the information in this questionnaire with potential recipient couples except my identifying information. I am not aware of any problems in myself, my family, or my current or previous sexual partners that were not answered in the above questions.

By submitting this contact form, you consent to receive email response(s) from the Center for Human Reproduction that contain health information. As email communications may not be secure even though the server from which we send our emails is secure, your submission of this form constitutes a request to communicate with us via email, as well as an acknowledgement that the email address you provided is accurate and that you accept full responsibility for messages sent to or from this address.

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